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Rapid Responses: Rapid Responses published:
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From blood pressure measurements to clinical decisions
- Tom P Marshall (2 September 2007)
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Three cheers for risk assessment
- Jonathan D Sleath (3 September 2007)
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Treat cardiovascular risk not blood pressure: leading from the front-line
- Paul D Rutter (3 September 2007)
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High Diastolics May Be "Good"
- John S Morley (4 September 2007)
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Tom P Marshall, Senior Lecturer University of Birmimgham, B15 2TT, UK
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Dr Nash argues that we should treat cardiovascular risk not blood pressure. This is clearly correct. Our objective is to prevent cardiovascular disease, not to normalise individual risk factors. There are further hazards in focusing on blood pressure as a single risk factor. Blood pressure is intrinsically variable, meaning that patients whose average blood pressure is 120/80 mm Hg will have a range of blood pressure measurements. This range is surprisingly wide and it greatly complicates clinical decision-making. It is hard to know when to start treatment. It is hard to know whether treatment is working. If any readers interested in the diagnosis and management of hypertension they might like to spend a few minutes taking part in a website-based study of doctor's decisions in diagnosing and treating hypertension. The web address is: http://www.clinicaldecisionresearch.org.uk/ Just log on and follow the instructions. Competing interests: None declared |
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Jonathan D Sleath, General Practitioner Kingstone, Hereford HR2 9HN
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I was delighted to read the editorial suggesting that we should move away from the primitive ‘one threshold fits all’ mentality for starting antihypertensive treatment, and take a view based on the overall cardiovascular risk. We already do this when treating cholesterol for the purposes of primary prevention, so it is inconsistent not to use this approach for blood pressure which is another continuous variable. The recent JBS guidelines recognise this as the predicted cardiovascular risk rises with systolic blood pressure to 160mmHg, yet they are not used as a tool for assessing whether or not to treat hypertension. This is part of the general problem that occurs when we assign arbitrary values to continuous and often fluctuating biological variables in order to create boundaries for disease labels. For example bronchial hyper-reactivity can change quite significantly over time and it can be very difficult to decide whether or not the label of asthma is appropriate. Our target-driven culture encourages the use of these labels, but I think that they are often not very helpful, and I often use asthma medications in those to whom I would not label as asthmatic. Glucose metabolism represents another such variable, and I look forward to the day when I read an editorial suggesting that we abandon the WHO criteria for diagnosing diabetes, in favour of a decision tool for the treatment of abnormal glucose metabolism based on risk. Competing interests: None declared |
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Paul D Rutter, SHO in General Practice Whitby Group Practice, Whitby, North Yorkshire, YO21 1SD
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Nash squarely frames hypertension management in its true context, the reduction of cardiovascular risk. General practitioners understand this to be the end-goal, but many practices in the United Kingdom deliver a service that may not reflect or communicate this. Nash also advocates viewing cardiovascular risk as a whole, but current systems and processes compound the tendency to compartmentalise individual risk factors. The holistic general practitioner would wish to consider diet, exercise, blood pressure, smoking and lipids with his patient, clearly communicating the aim as being the prevention of cardiovascular events. But the nurse-run clinic that his practice organises, ticking all of the boxes as far as NICE and the Quality and Outcomes Framework (QOF) are concerned, is a ‘hypertension clinic’. The goal is framed as the reduction of blood pressure. There is a danger that the true end-goal may slip from focus, for the patient and for the practitioner. Perhaps all hypertensive patients should instead attend a ‘stroke and heart attack prevention clinic’? This would explicitly communicate the reason for their antihypertensive medication. They would also be more likely to think and ask about cardiovascular risk factors beyond hypertension. If we have systems that centre on individual risk factors, our patients will concentrate on the risk factor itself; if we have systems and hence clinics that consider the risk in its broader sense, our patients will more readily see the bigger picture. Are we guilty of leading ourselves down the same narrow path? If we establish a ‘hypertension clinic’, we measure its success in mm Hg. At the back of our minds we know the reason for our efforts, but it is not at the forefront of every consultation, every service evaluation, and every attempt at improvement. It seems likely that guidelines will become more sophisticated, allowing practitioners to treat an individual in terms of their overall cardiovascular risk rather than as a collection of discrete risk factors. The detail will take time to elucidate. But embracing the principle is a task for those on the front line, who need not wait. They must focus on their systems, not just their own clinical practice. Even simply changing the name of the hypertension clinic would drive its improvement and lead to a broader approach, more focused on the true goal. And when more sophisticated guidelines do emerge, practices would already have the infrastructure and ethos in place to enact them. Competing interests: None declared |
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John S Morley, Retired Neurologist Pain Relief Foundation, Liverpool
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Current discussion of blood pressure (bp) in the context of overall cardiovascular risk largely ignores the relevance of diastolic bp. Yet the exhaustive data from the Framingham Heart Study show that, contrary to the situation in the case of systolic bp, there is an inverse relationship between diastolic bp and coronary heart disease, at any level of systolic bp (Franklin et al, ref 1). The results suggest the importance of pulse pressure in any of our considerations. For example, according to present definitions, a bp of 139/85 is regarded as high normal, and one of 129/75 as low normal. Yet the pulse pressure is 45mm Hg in each case. The same disregard of diastolic readings is evident in the recent prospective cohort study of Conen et al (ref 2). Presumably these authors have both systolic and diastolic readings for each of their 39,322 subjects. Recalculation of their results on the basis of diastolic and pulse pressures would be invaluable in supporting or otherwise Franklin's earlier analysis. J.S. Morley
References 1.Franklin SS,et al, Circulation, 1999,100:354-360 2. Conen D,et al, BMJ 2007, 335:432 (1 Sept) Competing interests: None declared |
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